integral clinical plan shared with or without telemonitoring of constants in patient with chronic diseases

Conditions: Chronic Lung Disease; Chronic Heart Disease

Summary: information and communications technologies (ict) currently constitute a key element in the innovation and improvement of providing health-care to frail populations with advanced chronic diseases, but it´s efficacy, safety and cost-effectiveness has not yet been proven conclusively. the investigators are going to carry out a multi-center, randomized, parallel groups, phase iii clinical trial in adult patient with heart and/or lung advanced diseases,aiming to analyze the efficacy and cost-efficacy of tele-monitorization of bio-parameters added to optimal standard of clinical care (shared clinical care plan) compared to the shared clinical care plan exclusively.

a total number of 510 patients will be divided in 3 centers: hospital university virgen del rocío; hospital university virgen macarena and public hospital comarcal of serranía de ronda. patient will be randomized in tele-monitoring constant (telepac) to analyze the efficacy and cost-efficacy of incorporating tele-monitoring of bio-parameters into the shared comprehensive clinical care plan or in standard clinical care (pac) based on a comprehensive clinical assistance shared between primary care and hospital care.

Eligibility criteria:
inclusion criteria: * majority legal age (18 years of age or older) * present any of the following shortcomings: heart failure with baseline dyspnea ≥iii of new york heart association (nyha) chronic respiratory insufficiency with basal dyspnea ≥iii of medical research council (mrc) scale and / or oxygen saturation \<90% and / or home oxygen therapy. * present heart failure or respiratory insufficiency with basal dyspnea grade \<iii (according to nyha and mrc respectively) but have presented 2 or more income in the last year. * score of patients with terminal or palliative medical diseases (score paliar) index between 0 and 7 points. * to present one of the following assistance situations: hospital admission, follow-up in home hospitalization or palliative care teams, specialized outpatient follow-up. * speak, understand, read and write spanish, either the patient or the primary caregiver. * have basic knowledge of the use of mobile phones and applications of computer tablets (such knowledge will be confirmed by personal interview, with test of the device). * informed consent to participate in the study exclusion criteria: * presence of malignant neoplastic disease active except localized adenocarcinoma of prostate in hormonal treatment, and / or cutaneous basocellular-squamous cell carcinoma. * in the case of chronic renal disease if there is the possibility of entry into substitutive therapies (hemodialysis or transplantation) * in the case of chronic liver disease, if there is a possibility of liver transplantation. * chronic neurological disease with established cognitive impairment (e. pfeiffer with 7 or more errors and / or mild cognitive evaluated (ecm with ≤18 points). * clinical situation of agony. * surprise question ("would you be surprised if your patient died in the next 6 months?") with the result "i would not be surprised" + paliar score score ≥7.5 points. * participate in another tele-health initiative. * go simultaneously to a private health service and / or be institutionalized